GW1-2022-03647_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well,Contractor Information:
Landon Phillips 14.WATER ZONES
Well Contractor Name FROM TO I DESCWTION
3441 A Zo O tt• rt. , 0
ft. ft.
NC Well Contractor Certification Number is.OUTER CASING for multi-cased wells OR LINER it a licable
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS I MATERIAL /
I ft., /t ft. in.
Company Name //� �� C_�/� 16.INNER CASING OR TUBIN eothermoI closed-loop)
2.Well Construction Permit#: (2 —' 0� 1 J (�(J�( FROM I TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fr.
3.Well Use(check well use): rt. ft. in.
Wafer Supply Well: 17,FROM SCREEN,TO DIAMETER SLOTSIZE THICKNUS 5ATERIAL
❑Agricultural ❑Municipal/Public ft. ft in
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. tr. in
❑hidustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑bTl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPI.ACE51ENT METHOD&AMOUNT
Nou-Water Supply Well: ft. G ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. f.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothennal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness suit/rock rain size etc.)
f ft. ft. Sd C
4.Date Well(s)Completed: ` _�` Well ID# ft. Q ft.
5a.Well Location: n ` tf 27 tf uu n,Y1
��r1f���L ft. ft.
Facility/Owner Name Fac tty ID#(if applicable)
ft. ft. 't
6 317 f2o��s� iZ ict spr ft. MAR 2 8 2022
Physical Address,City,and Zip �SG/G ft. ft.
PrOsessiRg
LA !� 21.REMARKS 11110FIRVOWUl
Cowrty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) —]Q Q 22.Certtiirrca�t'
3 5, Col I Lf N [ C� V �� W /� _ ���
6.Is(are)the well(s): ®Permanent or ❑Temporary Siffgnatureeof Certified Well Contractor Date `/ Z
By signing this form,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ®No 1 SA NCAC 01C.0100 or i5A NCAC 01C!0100 ll"ell Construction Standards and that a copy
Ijthis is a repair,fill out krrown ivell construction h formation and explain the nature of the of this record has been provided to the well owner.
repair under#21 rentarkt section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 22 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (R')
Submit this GW-1 within 30 days con
For multiple wells list all depths ifdii ferent(example-3@200'andd 2@I00) y of well completion per the following:
10.Static water level below top of casing: v (ft.)
24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over:100,000 GPD:Copy to DWR,CCPCUA
13a.field(gpm) 70 Method of test: Blow Permit Program,1611 MSC,Raleigh,:NC 27699-1611
13b.Disinfection type: HTH Amount: 1 Ib'
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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